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Tuesday, December 29, 2009

When my labour began I was ten days overdue and fed up of aching and waiting for my baby to come out. I had planned to have a homebirth and my mum and husband, David, were ready and waiting with me. In the early hours of Friday morning I remember standing in the kitchen doing squats while hanging on to the cupboards, as well as rolling my hips around whilst on all fours in the bedroom. Having undergone a 24 hour false labour (when I am sure baby Thomas twisted himself into an occiput posterior (OP) position), I didn't want to think this could actually be it. I got up and ignored the twinges and went shopping with my mum for food to feed us all over the weekend. Every other aisle we walked down I had to lean over the trolley and take a few breaths. Mum asked if I was having contractions and I denied anything was wrong up until the last couple of times when I admitted it was possible it was early labour but we weren't to get excited!

I count labour as properly starting when my waters (gently) broke whilst standing in the restaurant queue in the supermarket at midday having convinced myself my baby was never coming out! They didn't gush everywhere, there was just a definite "OH!" and then home we sped! From leaving the supermarket to getting home (10 mins away) my contractions went from 10 minutes apart to 4 minutes apart. By 1.15pm the contractions were suddenly 2 minutes apart. The midwife came at 1.45pm and I was 4cm dilated.Up to this point it was all going well and the ball and Hypnobirthing techniques were working well. The midwife said the baby was high up so it 'would be ages yet' and to bounce on the ball, although my mum pointed out that her labours had all progressed rapidly and her babies had dropped and been born in four pushes... up to this point the midwife was talking about leaving and coming back later. Anyway, she stayed and I bounced as the contractions got worse. They were every minute and were just so intense. I did some Hypnobirthing relaxation which really helped for a while and ended up in the birthing pool about 4pm. The pain was all in my back so I ended up having gas & air about ten minutes later. I couldn't have done it without it! Lots of positions later and I was trying to push so at 5pm I agreed to another examination only to find I was only 6cm dilated. Having experienced unrelenting non-stop contractions since 1.30pm, I only went 2cm in 3.5 hours! So then I started to panic...I went to the toilet and took my mum and David with me and remember sitting there and saying "I can't do this, it's too painful, it's too painful, I'm only 6cm, I can't do this" and then was told by the midwives (the two who were meant to be with me turned up just before I was examined) that they had discovered meconium in the waters so it was their policy to transfer to hospital AND that the baby was in the wrong position and I was in so much pain because I was having a back-to-back labour! David knew how much a natural birth meant to me and so stood firm and told them all to just wait while he talked to me himself. I had already decided at this point that I needed something else for the pain and the panic of only going two more centimetres had made me tense up and Hypnobirthing wasn't working and it was all going wrong so off to hospital we went... Nurrrr nuhhhh, nur nuhhhhhh, nur nuhhhh, 5.30pm through rush hour traffic with a lovely lovely ambulance man taking my mind off the pain and holding me over the bumps.We got to the hospital and I was still wound up and panicked and I agreed to having an epidural. I still find this unbelievable, a year on! Lucky for me, I hadn't had bloods taken since I was 37 weeks pregnant so they had to take bloods and everything took so long and so I ended up pleading for morphine in the interim. As it turned out morphine completely calmed me down and I got back into the swing of things, refused the epidural when they finally said I could have it and everything else is a bit of a blur! I managed to cope with the contraction pains mainly by lying on my back, which I thought was weird for a back labour but being on all fours to take the pressure off my back just hurt my knees and I was better with the gas & air on my back as I could take proper deep breaths which relaxed my body without me having to worry about falling off the bed!

Lots of positions later and at 8.45pm the midwife asked if I wanted to try and empty my bladder - which would mean getting up and leaving the room! Apparently I had around four contractions before making it to the toilet and then two on the toilet! When I stood up I did this squatting motion and was rolling my hips around and the midwife said I was just going with my body and listening to what it wanted to do. When we got back to the room and the midwife went to do an examination she discovered a head in my birth canal! This was much to her astonishment as she had earlier said that she was only on until 10pm and the baby wouldn't be born during her shift.

Push push push, lots of breathing down, breathing down, David said I was doing my Hynobirthing techniques brilliantly, lots of people in the room (three doctors, three midwives, David and mum, oh and me!) and gas & air. Really hard work but it felt so good to be doing something constructive and I could feel the head every time I had a contraction! And mum & David were telling me they could see the head and he had loads of hair! Push push push... and finally out his head popped! God the relief! Then on the next contraction out he popped! And everyone shouted "Look at the size of him!!!!!", he screamed immediately (which kind of defeated the purpose of the paediatricians being there to suck mucus out of him before he could inhale meconium), the cord was cut (which I’m still a bit sad about) and off he went to the resus table to be sucked and wiped clean and Apgar scored before being given back to me. The placenta easily popped out after twenty minutes.

OK, I'm going to stop here! All I can say is I seriously believe Hypnobirthing saved me from having an epidural and C-section and I was very proud to be told that most first time mothers don't end up having a natural birth with an OP (back-to-back) labour and I was a hero at the hospital with staff and other women alike for doing this without an epidural AND having a 10lb 8oz baby! So I am not sad I wasn't at home. I did start to panic as it all happened so quickly and things all went pear-shaped and I felt I needed the support of more people. Once at the hospital I calmed down a lot and I am really proud of what I managed to do. Hearing the story back from my mum and from David was just amazing, so much I had forgotten and yet remembered when told!

Friday, December 11, 2009

A few weeks ago I was out having dinner at an Italian restaurant when a fight broke out outside the pub next door. The mob grew bigger and chairs got thrown and a guy was knocked unconscious. Being at the back of the restaurant, I didn't like to go and 'gape' but after a few minutes, gape I did. Mainly because a woman at the table next to us was shouting at the waiter to "close the blinds, I don't want to see that kind of thing". When I went up to the window, I asked the other 'gapers' whether anyone had called the police. People looked away and shook their heads - the fight had been going on for a good five minutes! So I called the police and they arrived within a couple of minutes and all was well in the world again.

It got me thinking about people, and about myself. I couldn't have sat there and shut the blinds, knowing what was going on outside, yet the woman at the next table was seriously suggesting that this was a valid thing to do.

This morning as I walked to my bus stop on the way to work, I noticed a couple of lads across the street being aggressive towards a woman in her late 40s. She had learning difficulties and was getting quite vocal and upset. Instead of walking away, the boys started pushing her and eventually spat on her. They SPAT on her. The woman hit one of the boys on the arm and his response? He went to punch her. At this point, I ran across the road and stepped in betweeen the boys and the woman. The woman was sobbing and hanging on to me as I calmly asked the still abusive lads to walk on.

They eventually walked away and I took the woman to her local college where she was late for a class and then carried on to work.

Now I sit here and I ask myself... was I stupid or was I doing the right thing? It doesn't always pay to be a good Samaritan. But why do people respond so differently to situations? Out of the twenty or so people on the street this morning, there was only myself and one other man who went to help. Is it because of the media reporting so many situations where getting involved has been the wrong thing to do?

Sunday, December 6, 2009

My journey to become a doula started when I was pregnant with my first child. I enjoyed pregnancy so much and looked forward to the birth of my baby. The whole experience of pregnancy, labour and the first few months of motherhood was so empowering and life-changing and I knew that I wanted to make a difference to other people going through similar experiences. The role of the doula encompasses so much which is intrinsically important to me and through my research and reading I have come to understand so much more about the work involved. I know that this is just the start of my real journey; I now have the skills which will enable me to support women and their partners throughout their pregnancies and births, but the real work begins after this. Finding clients and truly helping people, this is where it all begins...

The first few days and weeks after labour can be a difficult and challenging time for a new family.Many people focus on pregnancy, labour and birth and don’t think about what happens once the new baby is born.This blog post has been added to discuss a few of the issues, challenges and parenting styles which new parents may experience.It is not meant in any way to be a complete guide to life after birth!

“Many women experience a sense of euphoria during the first few days following birth, fuelling a bout of physical energy that is brought to a standstill as the “baby blues” kick in around day four – when you can weep at the slightest cause or contradiction for 24 hours – then a gradual settling into the more day-to-day rhythm of life.” (Stockton, 2008)

If birth has been a traumatic experience this can affect the mother in many ways, including finding difficulties with bonding and breastfeeding.The presence of a doula immediately after birth can help establish a good settling-in routine for the mother and baby, as well as supporting the partner in his/her new role as caregiver to the new baby.Whether at home or in hospital, skin-to-skin contact between mother and baby should be encouraged soon after birth.This close contact helps the release of hormones to encourage milk production; warms the baby; soothes the baby after their journey into the world, by hearing the familiar sound of the mothers’ voice and heartbeat; and continuously develops the bond between mother and baby.A doula may help with initiating breastfeeding; if the mother wishes this kind of help (midwives may also be available both at home and in hospital).

A doula who has been present at the birth of a new baby will visit the family once they have returned home.This visit is used as an opportunity to talk about the birth and then discuss any issues the family may be having.Some families may want extended help in the weeks after birth and in these instances a post-partum doula can be hired.Post-partum doulas act as a family support and may do grocery shopping, cooking, cleaning, child-minding or any other job which helps the new family to relax and enjoy life.Doulas will come into the household with a list of resources to cover all aspects of life with a new baby – these may include numbers for midwives and health visitors; new parent support groups; breastfeeding helplines; local community support; baby massage; and alternative therapy clinics.

Many new parents feel a need to follow a ‘method’ for raising their child(ren).For some, the use of a book can make parents feel more in control in a world which has been thrown up in the air and the pieces scattered all around.Others can get so tied up in routines and habits that they start to stress that their baby doesn’t ‘do’ what he/she is meant to be doing, doesn’t sleep through the night, doesn’t nap at X time for X amount of time.All families are different and what works for some will not work for others so it is important for a doula to be aware of the many childcare methods that are available to new parents.Some parents believe that the baby should remain in their presence at all time, through the use of a sling, gentle holding and co-sleeping.Others rely on more ‘conventional’ methods such as Gina Ford, Dr. Spock and the Baby Whisperer, which implore parents to use routines and regimes to create the perfect baby.A doula should be aware of the many methods that parents may feel suit their lifestyles and environments best and therefore undertake to follow.

Most new mothers will expect to be able to breastfeed their new baby and for many women it is a rich, fulfilling experience but for others, it can be a challenging, emotional and traumatic time.It is the responsibility of the doula to ensure that a mother gets the physical and emotional support she needs during this time – through speaking with the partner / providing helpline numbers / or just listening to the mothers’ worries and fears.There are many support networks and techniques available to breastfeeding mothers, including National Childcare Trust (NCT), La Leche League, biological nurturing and local breastfeeding groups.

When breastfeeding goes well, it is a wonderful experience for both the mother and the baby.When it goes badly, it can lead to mothers feeling inadequate and like they have ‘failed’ to provide for their baby.A doula should be aware of the many conflicting feelings a woman may be feeling during this time and act appropriately.A woman may just need to be told that she is doing wel9l, or feel like someone understands what she is going through; alternatively, she may be looking for closure, or someone to tell her it is OK that she is not breastfeeding.Psychologically it is a sensitive time for many women and a doula has to be aware of this.

The policy of many hospitals in the UK is to induce labour if the pregnant woman is ten days over her due date. This may be decreased to seven days with older mums (>35) or increased to two weeks in some hospitals. This suggests that there are valid medical reasons to induce labour but this has not been proved through medical research. The guidelines issued by NICE state:

“Induced labour has an impact on the birth experience of women. It may be less efficient and is usually more painful than spontaneous labour, and epidural analgesia and assisted delivery are more likely to be required.”

In the UK, due dates are calculated by two methods – Naegele’s rule (introduced in the 1800’s) and ultrasound scanning. There is a lot of variability in the methods used for due date predictions; and also gestation times can vary from woman to woman. Several factors affect the accuracy of a due date: the length of a woman's menstrual cycle, her age, health, weight and the number of previous pregnancies all play a part. These factors, combined with the ‘overdue’ calculation, could easily lead to circumstances where the baby is not yet ready to be born, yet the mother feels obliged to undergo induction due to medical ‘rules’.

During natural labour, a number of different hormones are released by both the mother and the baby at different intervals, in different amounts and with different half-lifes. During an induced labour, synthetic hormones (normally synthetic oxytocin) are given via a continuous drip, rather than in a pulsatile manner. Drug-induced contractions can be longer, stronger and closer together than those experienced in natural labour, and can cause more pain in early labour than either a woman expects, or what she would have experienced if labour had been allowed to progress naturally. During an undisturbed labour, pain endorphins are released as labour progresses and these act as natural opiates which help the birthing woman to cope with the increasing pain of contractions. The use of induction drugs increases the need for pain medication which in turn increases the use of further interventions, including instrumental deliveries and Caesarean sections.

The results from an Australian study on interventions during labour in both primiparous (first-time mothers) and multiparous (given birth before) women between 2000 and 2002 demonstrate the effects of having an epidural for pain relief (Tracy et. al. 2007). Interestingly, the use of induction methods does not make a statistically significant difference to the birth outcome but the use of an epidural does. Instrumental and surgical births are greatly increased in both induced and spontaneous births when pain relief via epidural has been administered.

The choice of whether to be induced, and whether to accept medication for pain relief, should be discussed with both the mother and her partner before labour begins. Women often want to experience a natural birth but can change their minds during the course of labour, either due to medical advice, or because they firmly believe they need extra help. It is the role of the doula to remain calm during these conversations in the labour room, to remind the woman and/or her partner of her wishes, to suggest alternatives and lastly, to step back and allow the medical staff to do their job if a final decision has been made for pain medication. It has been shown that women respond to birth more positively if they feel that decisions were made with their full acknowledgement and informed consent.

The role of the doula becomes apparent during labour. A doula will be an invaluable source of support whether the mother-to-be wants a hospital birth or a home birth. Even with elective Caesarean sections, a doula may be required to act as a support for the mother, the partner and other family members. There is no birth where a doula is unneeded!

A doula is not a trained professional and, as such, remains present during labour and birth to support the mother (and partner). Her presence is continuous and may be invaluable in a hospital setting where midwives work in shifts and labour crosses many shift changes and tea breaks. Both in hospital and at home, a doula will begin by ‘preparing’ the room / labour space. Lights may dimmed, beds moved, ‘nests’ made and music and/or candles started. All of these details will have been discussed before the birth and the doula will remember these details when birth starts and all else gets forgotten. Her role is to create a safe environment in which the mother feels at ease, safe and relaxed.

The element of safety is incredibly important during labour, and some research has linked this to hormonal reactions within the body. Hormones such as adrenaline, which are produced if the mother is stressed, can stall labour in the same way it would stall an animal’s labour in the wild.

Although not a trained professional, a doula is able to help with non-medicating pain-relief methods. Some labouring women want the doula to remain in the room as a ‘presence’ with no hands-on support; whilst others benefit from a hands-on approach and will use the doula to provide pain relief, or to guide their partners in the use of non-medication methods. These methods may include massage, touching and/or stroking – light pressure on the small of the back can be incredibly relieving during a contraction; the use of hot and/or cold towels on the back, shoulders, neck and head; or just gentle words of encouragement. “You’re doing really well” and “You can do this, you ARE doing this” can make a huge difference when a woman is tired and feeling like she can’t cope any more. The doula can also guide the mother into new positions to help with labour pain. This is illustrated in excellent detail in an article by Penny Simkin, Comfort in Labor (2007).

A doula can also help with breathing techniques to cope with the pain of labour. Focusing on breathing is a very powerful pain relief technique which can be easily forgotten by labouring women and their partners when contractions become intense. Doulas will remain calm and remind them of the techniques which may have been practised over the past few weeks and months. This brings the focus back to the couple and allows them to properly explore the options available to them with an informed choice (something not always available in the hospital setting).

The role of the doula is to support the labouring women AND her partner during this time. It is essential for the partner (if present) to feel engaged in the labour and birth of their new baby and a doula will facilitate his or her interaction and subsequent bonding with the baby. A doula’s role is not a replacement to a partner and many partners report positively to the presence of the doula at their partner’s birth.

The progress of a woman’s labour can take many paths depending on what her wishes are beforehand. Most women want to experience an easy labour with no intervention and no induction but as the medicalised system has taken over from routine pregnancy care, the chances of induction and intervention are highly increased.

The Blessingway ceremony is just one form of birth preparation.There are many other ways in which a woman (and her partner) can prepare for birth and all families registered with the NHS (in the UK) are given the option of antenatal classes as they near the end of pregnancy.These classes can be beneficial for some, and certainly provide information concerning hospital policy, pain relief methods and possible interventions, but they don’t focus so much on actual ‘preparation’.Again, knowledge breeds confidence and for a woman to feel confident, she must feel prepared for all that can / may / will happen to her during labour.Birth preparation focuses on both physical and emotional preparation.

Labour has been likened to running a marathon, an extreme physical endurance for which the body must be prepared.Yoga and swimming can help to strengthen core muscles, encourage good posture and promote breathing techniques, whilst walking allows the woman to remain active and encourages the baby to get into a good birthing position.Optimal foetal positioning (OFP) can be used to help turn a baby who isn’t lying in the best position, and can also maintain the position of the baby up until labour (figure 1).

Figure 1 - taken from www.spinningbabies.com

Many babies who are found to be in the breech position (feet down, head up) can be gently encouraged to turn using OFP techniques, as well as other (less-researched, unvalidated!) methods.These include: shining a torch on the belly (the baby will move its head away from the light); doing somersaults in the swimming pool; and even talking to the baby and asking it to move.Consultants may try to move a baby using a method known as external cephalic version (ECV) which can be uncomfortable for the mother and only has an average success rate (~65%).It is therefore important to encourage good foetal positioning via good posture and other OFP techniques.

As well as preparing the body for labour, it is equally important to prepare the mind.Ina May Gaskin often talks about stalled labours being restarted once the woman has released an emotional stress.

“... I then learned that the woman in labour had been adopted and had confided to her friend that she had grown up afraid that her biological mother had died in childbirth.She was apparently too embarrassed or too far beyond speech to admit she was afraid of dying if she surrendered to the power of her labor.Once this profound fear was mentioned aloud, her cervix relaxed and displayed abilities it didn’t seem to possess earlier.It wasn’t long before it was completely open.A healthy baby was born within two hours of the mention of the secret fear.”

Many birth preparation methods involve discussing thoughts and fears surrounding labour and birth.This becomes increasingly important for mothers having a second baby where the first labour has not gone as hoped.Much of the work of doulas in the UK involves helping women who are planning a vaginal birth after a first Caesarean section (VBAC).In these cases it is important for a mother to understand what happened during the first birth, what interventions were given, when and why, in order for her to move on and believe that she is capable of giving birth naturally.Equally important is to help her understand that if a second Caesarean section becomes likely, then this is in no way a ‘failure’ to birth her baby.A traumatic birth experience (use of interventions such as instrumental delivery or surgical birth) may increase the likelihood of post-natal depression, increases the chance of the mother developing post-traumatic stress disorder (PTSD), and decrease the success of extended breastfeeding.There are many resources available to women who have suffered a birth trauma; and for those wishing to gain knowledge in VBACs, and alternative birthing methods (doulas, independent midwives, home births).

Saturday, December 5, 2009

There is a native American ritual which has, in recent years, been adapted by those interested in natural birth to encompass the pregnant woman in the final month of her pregnancy. The ceremony is called a Blessingway; it is a celebration of the woman and serves to empower her in her journey to motherhood.

“Blessingway ceremonies create a sacred and safe environment where a mother-to-be can explore the challenges and joys that lie before her as she approaches birthing and mothering. Surrounded by the most important women in her life, she gains a sense of power, confidence, and support that will help her rise to motherhood”.

The Blessingway ceremony can be as short or as long as the woman desires and is often organised by the doula or a close female friend. The ritual involves the gathering of female friends who act to nurture the woman and care for her. This may take the form of brushing her hair, or massaging her feet. Some women will have henna patterns ‘tattooed’ onto their belly, to highlight the growing baby within. It is truly a celebration of the female form and brings the focus back to the woman when all the excitement has been directed at the arrival of the new baby. In some ways a Blessingway is a baby shower for the mother!

Each female brings a bead to the ritual. As each woman strings her bead onto a necklace, she tells the receiver why she has chosen the bead, strengthening the power it holds within the necklace. Some women may choose a bead which reminds them of the mother-to-be; some select a bead reminiscent of their past; others may take a bead from their own jewellery, or jewellery passed on to them from family. All the beads hold significance and the necklace acts as a reminder of this celebration of new life and impending motherhood. During labour, the woman can wear the necklace, or keep it nearby, to remind her that all of her friends are thinking of her and empowering her on this journey.

The Blessingway ceremony may be formal or informal but no matter what form it takes, it will be remembered by the mother-to-be for many years to come.

During pregnancy a woman must not only adjust to the differences in her changing body but she must also prepare herself for the upcoming labour and birth of the new baby.A pregnant woman may feel a whole range of emotions, about the pregnancy itself; the labour; and also about life after the birth.It is important to make a woman feel confident in her ability to labour effectively, birth the baby and become a great mother after it is all over.Many people forget that life for the pregnant woman (and her family) continues for many days, weeks and months after the birth of her baby.

Confidence comes from knowledge and knowledge can come from many sources – family, friends, the medical profession (doctors, consultants, midwives), doulas and from the woman’s own desire to learn.There are many resources available, including books, journals, support groups and local networks, and the amount these are used varies a great deal from person to person.

As well as prepare for the birth, a woman must cherish the time when the baby is growing inside and find ways to relax, meditate, exercise and communicate with the baby.Different women enjoy different activities including walking, swimming, reflexology and prenatal massage.Swimming and yoga are especially popular – swimming can release a lot of the tension and tiredness which comes from carrying the extra weight, especially in the third trimester.Yoga can help to stretch sore muscles and is used as a mechanism to learn breathing techniques which can help with the pain of labour

Most towns and cities will have numerous classes available for pregnant women.An extra bonus of these antenatal classes is the chance to meet other pregnant women who will be expecting their babies at around the same time.Women can start to create a new support network of ‘new mums’ before motherhood even arrives.

Lay-person support of the labouring woman and her partner has been demonstrated to lead to lower active labour times and decreased intervention rates – including Caesarean sections, use of drugs for speeding up labour and/or for pain relief, forceps and ventouse delivery. The use of a doula can also decrease post-partum depression rates and increase the success of breastfeeding for a prolonged period after birth. There is no research to suggest that the use of a doula is detrimental in any way, yet the presence of a doula is not routinely requested or made available to pregnant women. Many people do not even know what a doula does, although organisations such as Doula UK (www.doula.org.uk), Doulas of North America (www.dona.org) and l'association Doulas de France (www.doulas.info), are working hard to make the doula name commonplace within society.

But why does it work? This is a question that remains unanswered, although many theories have been proposed. Like all mammals, pregnant women labour better in a comfortable environment where they feel safe. The hospital environment is not generally amenable to such a feeling but the presence of a doula can help calm the atmosphere and small changes to the labour room (dimming the lights, moving the bed, minimising the number of people present) can make a huge difference. A doula will help the partner(s) to nurture, love and support the labouring woman and will be a constant presence in an environment where the medical staff may change shifts, take breaks and work in teams. Overall, the presence of a doula can bring calm and security to the newly-emerging family and it allows them to focus when faced with challenges and questions from caregivers.

Doula, from the Greek doul, meaning servant-woman, slave, is the name given to modern-day birth support partners.Doulas act as ‘mothers supporting mothers’, an experienced lay-person accompanying the mother (and her partner) during her pregnancy, birth and subsequent life with a new baby.In the past this role has been undertaken by family or friends, when birth was less medicalised and women gave birth at home or surrounded by female supporters.As the process of birth was taken into the hospital, the need for support partners was undermined and forgotten.In recent years, the importance of birth support partners - people who can help focus, calm and be present at all times – has been recognised and the role of the ‘doula’ has emerged.